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Capitate Stress Injuries of Both Wrists in an Adolescent Female Gymnast: a Case Report Brynne R

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Capitate Stress Injuries of Both Wrists in an Adolescent Female Gymnast: a Case Report Brynne R Capitate Stress Injuries of Both Wrists in an Adolescent Female Gymnast: A Case Report Brynne R. W. Latterell, MPH*; Deana M. Mercer, MD†; Shane P. Cass, DO‡; Christopher A. McGrew, MD†‡ *School of Medicine, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico †Department of Family & Community Medicine, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico ‡Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico Abstract Published case reports are limited on capitate stress injury.5,6 One study5 involved a 42-year-old male physical- Gymnastic activities expose the wrist to a wide variety of education teacher who was instructing gymnastics; the overuse and acute stresses. Injuries to the distal radius are other6 described a 30-year-old male dock worker who the most commonly reported gymnastic wrist condition; developed a capitate stress fracture after months of using however, many other structures are at risk of injury from a lever to operate heavy machinery. Another study7 the sport’s high acute and overuse demands, including the radiographically reported a group of 18 children with carpal bones, most commonly the scaphoid. We describe capitate stress fractures among a larger collection of tarsal a 17-year-old female, high-level gymnast in whom stress and carpal cases in a 30-year period. However, this study injuries to both capitate bones were ultimately diagnosed did not include specific demographic characteristics of after initial symptoms of pain. This case demonstrated the patients such as gender and activities. need for prompt recognition, without which much chronic We describe the eventual diagnosis of stress injuries to and debilitating injury would develop. For successful both capitate bones of a 17-year-old, high-level gymnast, diagnosis, healthcare providers should carefully examine who initially presented with 2 months of pain in both and evaluate reported wrist pain in high-level, adolescent wrists. The patient and her mother were informed that gymnasts. the data concerning the case would be submitted for publication, and they provided verbal consent. Introduction Case Report Acute and chronic upper-extremity injuries are common in gymnasts. Typical injuries in female gymnasts involve the A 17-year-old, female gymnast presented to the sports- wrist, whereas men often report shoulder injuries.1 In one medicine clinic with pain in both of her wrists for 2 systematic review examining wrist injuries in adolescent months. She started participating in gymnastics at age 5 athletes, gymnastics was the most common sport years and began competing at age 12. Four months prior to reported.2 During gymnastic activities, the wrist is exposed initial presentation, the intensity of her practices increased to many different types of stresses, including repetitive when she began training with a new coach. The patient did motion, high impact loading, axial compression, torsional not recall a specific single traumatic episode. Of the four forces, and distraction in varying degrees of ulnar or radial gymnastic events, the balance beam bothered her the most. deviation and hyperextension.1 The patient was healthy; she had regular menstrual periods Radial epiphysitis is a frequent cause of wrist pain and since age 13 years, did not smoke or use tobacco, and injury in young gymnasts.1-4 Other diagnoses include reported no previous stress fractures. scaphoid impaction syndrome, dorsal impingement, Results of physical examinations indicated no obvious scaphoid fractures, scaphoid stress reactions and fractures, wrist deformities. The patient had decreased extension ganglia, carpal instability, triangular fibrocartilage complex and flexion on both wrists, with mildly limited supination. tears, ulnar impaction syndrome, and lunotriquetral She had tenderness over the distal radius, ulna, and dorsal impingement.1 wrist but not specifically over the capitate. Findings of her Case Reports 140 neurovascular examination and elbows test were normal. A Plain radiographs of the forearm and wrist showed closed physes, but findings were otherwise unremarkable. At this point, the family agreed to obtain magnetic resonance imaging (MRI) of both wrists to investigate the source of the pain. The patient was instructed to avoid painful activity and wear braces to help limit wrist hyperextension while waiting for the MRI results. The MRI revealed stress injuries of the capitate bones in both wrists. The patient was referred to a pediatric orthopaedist who reviewed the imaging. The surgeon B noted a stress fracture of the distal third of the left capitate and stress reaction of the right distal capitate, caused by hyperextension, with a likely mechanism of metacarpal- capitate abutment (Figures 1A through 3A). The injury was less severe in the right wrist compared with the left, with limited signs of edema (Figures 1B and 2B) and no fracture line (Figures 1B and 3B). The patient continued wearing the braces to prevent hyperextension of the wrists and was asked to avoid gymnastic activity for 6 to 12 weeks. At 6 weeks after the MRIs revealed the injury, the patient Figure 2. T2-weighted magnetic resonance imaging of the (A) left wrist and (B) right wrist, showing coronal view of capitate edema (white reported no pain in her wrists. Physical examination asterisk) and a fracture line (arrow) extending transversely in the distal findings were normal, with a full range of motion and third of the capitate. Notably, on the right wrist, the edema is less severe no dorsal tenderness of her wrist. She was directed to and no fracture line is seen. gradually resume activity, with progressive symptom- limited training, and return to the clinic if she felt pain. The A patient did not return for any subsequent visit. A B B Figure 3. T1-weighted magnetic resonance imaging of the (A) left wrist Figure 1. T2-weighted magnetic resonance imaging of the (A) left wrist and (B) right wrist, showing coronal view of the capitate fracture line and (B) right wrist, showing sagittal view of the capitate edema (white (arrow) extending transversely in the distal third of the capitate. Notably, asterisk) and a fracture line (arrow) extending from volar proximal to the fracture line is not visible on the right wrist, indicating a less severe dorsal distal in the distal third of the capitate. Notably, on the right wrist, injury compared with the left wrist. the edema is less severe and no fracture line is seen. 141 The University of New Mexico Orthopaedics Research Journal • Volume 6, 2017 Discussion Conflict of Interest This is the first case report of a capitate stress fracture in an The authors report no conflicts of interest. adolescent female athlete. The exact mechanism of injury to the capitate bone is complex; however, the axis-based References position of the capitate may cause strain during ulnar 6 and radial deviation of the wrist. In the current case, the 1. Webb BG, Rettig LA. Gymnastic wrist injuries. MRI revealed a less severe stress injury of the right wrist Curr Sports Med Rep 2008;7(5):289-95. doi: 10.1249/ compared to the left, which could indicate that a higher JSR.0b013e3181870471. level of force was applied to the left wrist during gymnastic 2. Kox LS, Kuijer PP, Kerkhoffs GM, Maas M, Frings- activity. However, it could also be due to frequency of Dresen MH. Prevalence, incidence and risk factors wrist bearing and strain, specific positions of the wrist, as for overuse injuries of the wrist in young athletes: a well as many other variables. Furthermore, this patient systematic review. Br J Sports Med 2015;49(18):1189-96. met two out of three key risk factors detailed in a study of doi: 10.1136/bjsports-2014-094492. overuse injuries in young athletes including early onset 3. Wolf MR, Avery D, Wolf JM. Upper extremity injuries of training (our patient started training at age 12) and in gymnasts. Hand Clin 2017;33(1):187-197. doi: sudden increase in training intensity (our patient increased 10.1016/j.hcl.2016.08.010. 2 training intensity with her new coach). Other risk factors 4. Poletto ED, Pollock AN. Radial epiphysitis (aka mentioned in a study specifically on young competitive gymnast wrist). Pediatr Emerg Care 2012;28(5):484-5. female gymnasts included recent injury, periods of rapid doi: 10.1097/PEC.0b013e318259a5cc. bone growth, low level of bone maturation, and advanced 5. Allen H, Gibbon WW, Evans RJ. Stress fracture of the 9 levels of training and competition. capitate. J Accid Emerg Med 1994;11(1):59-60. Standard treatment for overuse injuries such as a 6. Vizkelety T, Wouters HW. Stress fracture of the stress fracture involves relative rest, allowing non-painful capitate. Arch Chir Neerl 1972;24(1):47-57. activities with appropriate bracing to limit extremes of 7. Oestreich AE, Bhojwani N. Stress fractures of ankle 1,3,8 motion. Return to participation is usually over a 6- to and wrist in childhood: nature and frequency. Pediatr 12-week timeframe, depending on severity of symptoms, Radiol 2010;40(8):1387-9. doi: 10.1007/s00247-010- findings of physical examination, and, though less common, 1577-y. 1,3,8 findings of repeat imaging. If untreated, capitate stress 8. Jones GL. Upper extremity stress fractures. Clin Sports fractures may result in possible career-altering or ending Med 25(1):159-74. doi: 10.1016/j.csm.2005.08.008. outcomes for patients. Complications include fracture 9. Caine D, Cochrane B, Caine C, Zemper E. An displacement, non-union in fractures involving the cortical epidemiologic investigation of injuries affecting bone, malunion of displaced fractures, avascular necrosis young competitive female gymnasts. American associated with chronic pain, loss of range of motion, and Journal of Sports Med 2016;17(6):811-20. doi: 1-6 need for surgical intervention.
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